Guidelines for Food Fortification and. Use of Oral Nutritional Supplements. in Adults

Transcription

1 Guidelines for Food Fortification and Use of Oral Nutritional Supplements in Adults Produced by: TAG Nutrition Sub Committee with special thanks to the dietitian members of this committee from all local Trusts for their expert input Issue Date: September 2013 Review: September

2 STANDARDS TO FOLLOW CQC Outcome 5 - Meeting nutritional needs Where food and hydration are provided to service users as a component of the carrying on of the regulated activity, the registered person must ensure that service users are protected from the risks of inadequate nutrition and dehydration, by means of the provision of: a choice of suitable and nutritious food and hydration, in sufficient quantities to meet service user s needs; food and hydration that meet any reasonable requirements arising from a service user s religious or cultural background; and support, where necessary, for the purposes of enabling service users to eat and drink sufficient amounts for their needs. For the purposes of this regulation, food and hydration includes, where applicable, parenteral nutrition and the administration of dietary supplements where prescribed. Regulation 14 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 NICE Quality Standard for Nutrition Support in Adults Describes markers of high-quality, cost-effective care that, when delivered collectively, should contribute to improving the effectiveness, safety and experience of care for people requiring nutritional support in the following ways: Preventing people from dying prematurely. Enhancing quality of life for people with long-term conditions. Helping people to recover from episodes of ill health or following injury. Ensuring that people have a positive experience of care. Treating and caring for people in a safe environment and protecting them from avoidable harm. ACBS Guidelines Explains when prescribing nutritional supplements on NHS FP10 prescription is appropriate The ACBS indications for ONS are: pre-operative preparation of malnourished patients proven inflammatory bowel diseases short bowel syndrome intractable malabsorption post-total gastrectomy dysphagia bowel fistulae disease related malnutrition. 2

3 GUIDING PRINCIPLES FOR IMPROVING THE SYSTEMS AND PROCESSES FOR ONS USE National Prescribing Centre 2012 (endorsed by NICE QS) 1. Local health economies should understand their local clinical need for adult oral nutrition support and map this against local work force expertise 2. Local health economies should understand their local procurement arrangements for adult ONS in primary, secondary and social care. 3. Commissioners should review prescribing arrangements for adult ONS. 4. Local health economies should ensure that a validated screening tool such as the Malnutrition Universal Screening Tool ( MUST ) is embedded into everyday care so that the results of screening are linked to a care plan. 5. Local health economies should develop standard templates for care plans to be used with at risk adult patients across primary, secondary and social care. 6. Goals should be set and the care plan monitored and reviewed so that oral nutritional supplements are used appropriately. 7. Local health economies should work with care home commissioners and providers to ensure high standards of nutritional screening, education and assessment for oral nutritional support is embedded in the care home environment. 8. Local health economies should assess local training needs for all health and social care staff for the identification and treatment of adult under-nutrition and implement an education programme for all appropriate front line staff, carers and patients. 9. Competencies for basic skills should be developed. 10. Local health economies should develop measurements for assessing the quality of the provision of adult ONS. 11. Commissioners should consider incentives to improve adult oral nutrition support and prescribing practice. 12. Local health economies should consider setting up local forums to oversee nutrition issues in primary, secondary and social care with an emphasis on the interface. 3

4 AIM OF THIS GUIDELINE That adult patients receive appropriate nutritional advice and treatment in accordance with NICE CG 32 and NICE Quality Standard To meet the requirements of Outcome 5 of the CQC Standards Meeting Nutritional Needs Cost effective, evidence based, ACBS prescribing of oral nutritional supplements (ONS) Recommendations (from NICE Quality Standard) People in all care settings are screened for malnutrition and the risk of malnutrition using a validated screening tool All people who are screened for malnutrition or the risk of malnutrition have their screening results and nutritional support goals (where applicable), documented in their care plan at key stages of their care People who need nutrition support are offered treatment that, in combination with any dietary intake, provides their complete nutritional requirements People (and/or the carers of people) managing their own artificial nutrition support are trained to recognise and respond to adverse changes in their wellbeing and in the management of their nutritional delivery system People receiving nutritional support are offered a review of the indications, route, risks, benefits and goals of nutritional support at planned intervals by a healthcare professional People access nutritional care that is overseen by a nutrition steering group NICE has produced an elearning tool to assist in MUST training: The direct link to the MUST tool is: 4

5 NICE NUTRITION GUIDELINE CG 32 RECOMMENDATIONS FOR TREATMENT Nutrition support should be considered in people who are malnourished, as defined by any of the following: a BMI of less than 18.5 kg/m 2 unintentional weight loss greater than 10% within the last 3 6 months a BMI of less than 20 kg/m 2 and unintentional weight loss greater than 5% within the last 3 6 months. Nutrition support should be considered in people at risk of malnutrition who, as defined by any of the following: have eaten little or nothing for more than 5 days and/or are likely to eat little or nothing for the next 5 days or longer have a poor absorptive capacity, and/or have high nutrient losses and/or have increased nutritional needs from causes such as catabolism. Healthcare professionals should consider using oral, enteral or parenteral nutrition support, alone or in combination, for people who are either malnourished or at risk of malnutrition, as defined above. Potential swallowing problems should be taken into account. Healthcare professionals involved in starting or stopping nutrition support should: obtain consent from the patient if he or she is competent act in the patient's best interest if he or she is not competent to give consent be aware that the provision of nutrition support is not always appropriate. Decisions on withholding or withdrawing of nutrition support require a consideration of both ethical and legal principles (both at common law and statute including the Human Rights Act 1998). When such decisions are being made guidance issued by the General Medical Council 1 and the Department of Health 2 should be followed Healthcare professionals should ensure that people having nutrition support, and their carers, are kept fully informed about their treatment. They should also have access to appropriate information and be given the opportunity to discuss diagnosis and treatment options References:

6 CARE: THESE GUIDELINES MAY NOT BE APPROPRIATE FOR: If the patient has dysphagia, and is not already under the care of Speech and Language Therapy (SLT), please ensure that a referral is made to SLT before, or concurrent with, referral to a Dietitian. Community SLTs in Norfolk will only accept referrals from Medical Practitioners. SLTs working in the learning disability service will also accept referrals from primary care staff. Referrals should be sent directly to the relevant community learning disability team. These patients should be referred to the specialist learning disabilities Dietitian. Also, adults with a learning disability and dysphagia should be referred to a Dietitian and SLT via the learning disability service. These will normally include conditions that require dietary modification as part of treatment. For example: Gastroenterology conditions such as Coeliac Disease Inflammatory bowel disease, irritable bowel syndrome Diabetes Renal impairment requiring restrictions to potassium and other nutrients Allergies/intolerances Enteral feeding All these patients should be referred to a Dietitian. All referral forms are available on Knowledge Anglia at: Adults in late palliative care Late palliative care is defined as: the patient s condition is generally deteriorating, they are experiencing increasing fatigue and reduced appetite. Other symptoms, such as nausea and pain may have worsened. Emphasis should be placed on the enjoyment of food and drink. 6

7 SUMMARY OF LOCAL RECOMMENDATIONS 1. Follow NICE guidance and use the MUST Tool to assess risk of malnutrition. See Step 1 below. 2. If a patient is identified as at risk of malnutrition the health care professional screening the patient should record baseline measurements and normally give initial advice of food fortification i.e. a Food First approach. See Step 2 below 3. If a patient is at high risk of malnutrition (e.g. MUST score 2 or more), over the counter (OTC) nutritional supplements (e.g. Buildup, Complan), should be recommended before prescription of oral nutritional supplements (ONS) is considered. Record baseline measures. See Step 3 below. 4. If Food First and OTC supplements do not result in improved nutritional intake and/or increased, or stabilised, weight within two to four weeks based on change in baseline measures, the patient should be referred to a Dietitian. See Step 4 below. 5. The Dietitian s assessment may indicate the need for a prescribable ONS according to the specific Advisory Committee on Borderline Substances (ACBS) conditions laid out in the NHS Drug Tariff. See Step 5 below. 6. If prescribed, a maximum of 7 days supply should be issued in the first instance to assess product acceptance and compliance. See Step 5 below. 7. Two supplements per day should be recommended (as supplements between usual food) unless otherwise requested by the Dietitian. 8. The Dietitian or prescriber should review the patient, as appropriate, and amend advice as required, e.g. stopping ONS. 9. Monthly repeat of measurements is required to monitor progress. 10. Dietitians will provide appropriate feedback and documentation to referrers regarding the assessment and treatment plan. 11. ONS should not be put on repeat as regular review is required. 7

8 Screen the patient for risk of malnutrition and initiate nutrition support as advised below. Take baseline measures of height and weight to calculate BMI. If not possible to measure height and weight follow guidance in MUST. Do not refer the patient at this stage. MUST SCORE RISK CATEGORY ACTION 0 Low If taking ONS review need 1 Medium Give Food First Advice 2 High Give Food First Advice & recommend OTC supplements MUST is recommended by NICE, but if not using MUST, the screening tool used should identify risk of malnutrition using the following factors: 1. BMI below 18.5kg/m 2 2. BMI below 20 kg/m 2 and unintentional weight loss greater than 5% within the last 3-6 months 3. Unintentional weight loss of 10% or more in the last 3 6 months Actions: 1. If there is 1 risk factor give Food First advice (see step 2 below) 2. If there are 2 or more risk factors give Food First advice (see step 2 below) and recommend OTC supplements (see step 3 below) If you have any queries or require training on the use of MUST and nutrition support, please contact your local Dietitians. NNUH: MUST.help@nnuh.nhs.uk West Norfolk CCG: contact Department of Nutrition and Dietetics, Queen Elizabeth Hospital on GYW CCG: contact Community Dietetic Department, Locality Offices, Lowestoft Hospital on

9 Food First means adding calories and protein to the diet by food fortification. Low-fat/reduced calorie foods should be avoided and full fat and high sugar products used wherever possible. Eating small, frequent meals and snacks may be easier than 3 larger meals per day. High protein/high calorie meals, snacks and drinks should be encouraged Fortified milk should be recommended. Fortified milk is made by the addition of 4 tablespoons of skimmed milk powder to each ½ litre (500ml) or pint of whole milk. Butter/margarine, cheese, cream should be added to appropriate foods. Sugar, honey, syrup and jams may also be added if the patient does not have diabetes. Recommended leaflets and booklets with recipes are available from your local Trust dietitians and at the following links: (Nutrition Toolkit)(registration required -note some PresQIPP documents are readily available on Knowledge Anglia) Many patients with dementia may have changes to their eating habits and ability to eat. A range of problems may be present, e.g. malnutrition, excessive weight gain, swallowing difficulties or the need to have foods presented in a different form, e.g. finger foods. 9

10 These can be purchased in most chemists and supermarkets. The most common ones are listed below and typically less than 1 per sachet. Build-up soup (made with water) Supplement Build-up (made with full fat milk) Volume per serving when made up 150ml 200ml Calories per serving when made up 200kcal 260kcal Build-up (made with fortified milk)* 200ml 330kcal Complan (made with water) 200ml 250kcal Complan (made with semi-skimmed milk) 200ml 320kcal Complan (made with full fat milk) 200ml 380kcal Complan (made with fortified milk)* 200ml 450kcal * Fortified milk is made by whisking 4 tablespoons of skimmed milk powder into ½ litre (500ml) or one pint of whole milk. 10

11 Prior to referring to a Dietitian you must have followed Steps 1 3 to ensure appropriate use of NHS resources. A Dietitian will accept a referral from any Health Practitioner. Residents in Care Homes should be referred by their GP. The referral forms for each Dietetic Department are available on Knowledge Anglia at: Additional information, e.g. copies of reports, can be attached to the referral form. S/he will triage the patient using information contained in the referral. Following triage, the patient will be assessed by a Dietitian or an appropriately qualified Assistant Practitioner (AP). From the assessment, recommendations will be made for appropriate dietary intervention which may include prescription of ONS for a seven day trial. Alternatively, the Dietitian or AP may provide samples of ONS for a trial period. When palatability has been established, a recommendation may be made for prescription of ONS for up to three months before next review. See Step 5 Recommendations will be documented and provided to the relevant stakeholders (e.g. the patient, the referrer, GP, carer) Will normally include: Anthropometric data MUST score Rationale for choice of ONS and recommended dose ACBS indication Anticipated outcome Plan for monitoring/review of progress Discharge plan In the interim, based on findings from the MUST assessment, if ONS is thought necessary and ACBS conditions are met, prescribe a maximum of two supplements per day for up to one month, following the guidance in Step 5 below. 11

12 The Dietitian s assessment may indicate the need for a prescribable ONS according to the specific ACBS conditions laid out in the NHS Drug Tariff. People with diabetes may need their blood glucose to be monitored Sachets need to be mixed before use so are only suitable for patients with carer support or who can make it up themselves. If the patient has dysphagia please see guidelines above for referral to SLT If the patient already has a SLT careplan is additional advice from SLT needed on thickening their supplements? The patient s religious, ethnic and cultural requirements The patient s beliefs that guide their nutrition e.g. vegetarian. These patients should be referred to a Dietitian. Flavour preferences Flavour fatigue (i.e. assorted flavours may be preferable) It is recommended that if a prescription of ONS is made prior to a dietetic referral it should be for a maximum of two weeks (i.e. if prescription is arranged at the same time as the referral to a Dietitian). Ideally the first prescription for ONS should be for no longer than 7 days, to avoid waste that may be caused by non-compliance due to, e.g. palatability of supplement. The usual quantity to prescribe in the absence of dietetic advice is one supplement twice a day between usual meals. Some products which may be of use in the interim between referral and dietetic assessment are listed below. Other products should not normally be prescribed without advice from a Dietitian. The Dietitian or prescriber should review the patient, as appropriate, and amend advice as required (e.g. stopping ONS). Suitable snacks, food fortification as well as OTC products can be used to improve the nutritional intake of those at risk of malnutrition. Where indicated according to ACBS, sachets requiring reconstitution with whole or fortified milk may be a suitable choice prior to review by the Dietitian. 12

13 The following prescribable products may be of use for the interim period between referral and dietetic assessment in accordance with the ACBS rules given on page 2 Product Comments Flavours Volume per serving Calories per serving Powder shakes e.g. Complan, Fresubin Powder Extra Mixed with 200ml whole milk Contains lactose Mixed with 200ml fortified milk Contains lactose Various 200ml when mixed 387kcal 450kcal Sip Feed Ensure Plus Strawberry, fruits of the forest and raspberry not suitable for vegetarians. Lactose and gluten free. Various 220ml 330kcal Sip Feed Fortisip Bottle Strawberry and tropical fruits not suitable for vegetarians. Lactose and gluten free. Various 200ml 300kcal Sip Feed Fresubin Energy Not suitable for vegetarians. Lactose and gluten free. Various 200ml 300kcal Sip Feed Resource Energy Minimum pack size 4 x 200ml Various 200ml 300kcal Can also get similar products with added fibre Opened, or reconstituted, ONS should be discarded after 24 hours. The supplements can be warmed if this is preferred COST: Significant differences may exist in terms of cost per treatment per day.. Please contact your prescribing adviser for costs for your CCG. 13

14 Product Comments Flavours Volume per serving Calories per serving Ensure Plus Juce (Abbott) Strawberry and fruit punch not suitable for vegetarians. Lactose and gluten free Fat free Various 220ml Fortijuce (Nutricia) Strawberry and forest fruits not suitable for vegetarians. Lactose and gluten free Fat free Various 200ml Fresubin Jucy (Fresenius-Kabi) Lactose and gluten free Fat free Minimum pack size 4x200ml Various 200ml Resource Fruit Minimum pack size 4x200ml Various 200ml COST: Significant differences may exist in terms of cost per treatment per day. Please contact your prescribing adviser for costs for your CCG. Product Comments Flavours Volume per serving Calories per serving Calshake (made with whole milk) Gluten free. Contains lactose Banana, neutral, strawberry, vanilla 300ml Enshake (made with whole milk) Contains lactose Banana, chocolate, strawberry, vanilla 300ml Scandishake (made with whole milk) Gluten free. Contains lactose Banana, caramel, chocolate, strawberry, vanilla, unflavoured. 300ml COST: Significant differences may exist in terms of cost per treatment per day.. Please contact your prescribing adviser for costs for your CCG. 14

15 MUST Screening Tool Prescribing Adviser Contact Information CCG Area Prescribing Adviser Contact Details: West Norfolk Debbie Craven / North Norfolk Christine Walton christine.walton@nhs.net / Norwich Ian Small ian.small@nhs.net / South Norfolk John Reuben john.reuben@nhs.net / Gt Yarmouth & Waveney Michael Dennis Michael.dennis@nhs.net /